Social Science & Medicine 52 (2001) 1677–1687 The ethics of social risk reduction in the era of the biological brain $ Ted Schrecker a, *, Lisa Acosta b , Margaret A. Somerville a , Harold J. Bursztajn c a McGill Centre for Medicine, Ethics and Law, 3690 Peel Street, Montre ´al, Que ´bec, Canada H3A 1W9 b Rush Medical College, 1524 West Harrison, #2A, Chicago, IL 60607, USA c Program in Psychiatry and Law, Harvard Medical School, Cambridge, MA 02138, USA Abstract In keeping with our transdisciplinary orientation, in this article we try to do several things at once. We address research on preventing mental illness and its relation to existing conceptions of public health, a topic to which insufficient attention has been paid in the era of the biological brain, while using this case study to illustrate the limits of conventional approaches in bioethics. After identifying the crucial need for methodological self-consciousness in prevention research and policy, we explore the implications as they relate to (i) the values embedded in the choice of research designs and strategies, and (ii) contrasting intellectual starting points regarding the biological plausibility of preventing mental illness. We then draw attention to the need for more thoughtful analysis of the appropriate role and limits of economics in making choices about prevention of mental illness. # 2001 Elsevier Science Ltd. All rights reserved. Keywords: Mental illness; Prevention; Public health; Methodology; Economics; Ethics Introduction The chapter on prevention in a recent text on mental health planning begins: ‘‘The proposition that it is better to prevent illness than to allow it to occur with its associated suffering, loss of function, and need for treatment, is one of the basic premises of public health that requires no justification’’ (Breakey, 1996, p. 323). Public health as a profession and a field of inquiry is undeniably organized around the premise that preven- tion is valuable; thus, the substance of public health has been defined as ‘‘organized community efforts aimed at the prevention of disease and the promotion of health’’ (Remington 1988, p. 41). Attaching high priority to prevention also fits well with the commitments to non- maleficence and beneficence that are widely acknowl- edged as central principles of bioethics (Beauchamp & Childress, 1994, pp. 189–325). However, few proposi- tions in public health or public policy require no justification. This point is particularly evident in the literature on preventing mental illness, where the case for preventive interventions is often made primarily on economic grounds. Implicit in this argument, if seldom acknowledged or defended, is the premise that alloca- tions of resources to prevention require justification, and some do not make the grade. This is a normative proposition; it can be neither established nor refuted on scientific grounds. In this respect as in several others, the prevention of mental illness raises complex ethical issues at the interface of science, public policy, law and clinical practice. Such $ This article is dedicated, with deep respect and a sense of great loss, to the late Jonathan Mann. Among the many ways he contributed to making the world a better place, his work in joining ethical analysis and public health, both in theory and in practice, has given to us all a legacy for the future. For this and much more, we are all in his debt. *Correspondence address. 450, rue de la Congre´gation, Montre´al, Quebec, Canada H3K 2H7. Fax: 514-932-5230. E-mail addresses: tschrecker@sympatico.ca (T. Schrecker), lacosta@rushu.rush.edu (L. Acosta), somerville@falaw.lan.mc- gill.ca (M.A. Somerville), haroldbursztajn@hms.harvard.edu (H.J. Bursztajn). 0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved. PII:S0277-9536(00)00281-1